4a Co-Living - Tiago Miranda - Social design projects

20 - Bienestar Familia - D4SB
Private Healthcare Insurance for Low Income Families
Bienestar Familia

26 - Colombia · Bienestar Familia - D4SB 27
Grameen Caldas is an organization founded in Colombia by GCL in partnership with the public sector represented by
the Caldas Government to facilitate the creation of a Holistic Social Business Movement (HSBM) in the region. The idea
of this HSBM is to set the right environment in Caldas paving the way for social business initiatives with the unique
objective of eradicating poverty. To enable this environment, Grameen Caldas set initiatives in micro-finance, joint
ventures development and in the creation of a social business fund of $7 million. The four main areas of investment are
education, nutrition, healthcare and housing (sanitation).
The Grameen Caldas team initiated Bienestar, a social business project addressing the issues of healthcare in the
region. Our challenge as the Design for Social Business team was to understand the complexity of the healthcare
system in Caldas, identify its main breakdowns and accordingly explore how design can improve, expand and replicate
the already existing pilot model of Bienestar.
Why Colombia?

The
Colombian
Context

31
Colombia
Proﬁle
Colombia in Numbers
Being the twenty-sixth largest country by geographical area and the twenty-seventh largest by population, the
Republic of Colombia is the fourth largest economy of Latin America. With over 46 million people Colombia (2010 est.),
has one of the most unequal distributions of wealth with a GINI coefﬁcient of 0.587 (the highest in Latin America).
46% of the population lives below the poverty line and 17% in extreme poverty.
People below
the poverty line
Rural and urban
populations
Unemployment
(total labor force)
Literacy rate
(age 15 and above)
Poverty head count ratio
at national poverty line
Capital City: Bogotá
Income Level: Lower middle income
GDP: $435,367,000,00 (2010 est.)
GNI per Capita: $8,430 (2009 est.)
GINI Index: 0.587 the highest in Latin America
Total Population: 46.3 millions
75%
urban
25%
rural
54%
above
88%
employed
93%
literate
62.8%
not poor
37.2%
poor
46%
below

MDG in Colombia
With a GINI coefficient of 0.587
Colombia has the highest inequality
in Latin America.
Goal
Value
1990
Value
2008
Goal 1. Halve the rates for extreme poverty and malnutrition
Poverty headcount ratio at USD$1.25 a day (PPP, % of population) - -
Poverty headcount ratio at national poverty line (% of population) - -
Share of income or consumption to the poorest quintile (%) 3.4 2.9
Prevalence of malnutrition (% of children under 5) - 5.1
Goal 2. Ensure that children are able to complete primary schooling
Primary school enrolment (net, %) 68 88
Primary school completion rate (% of relevant age group) 67 65
Secondary school enrolment (gross, %) 50 82
Youth literacy rate (% of people ages 15 - 24) 95 97
Goal 3. Eliminate gender disparity in education and empower women
Ratio of girls to boys in primary and secondary education (%) 108 104
Women employed in the non agricultural sector (% of non agricultural employment) 44 48
Proportion of seats held by women in national parliament (%) 5 8
Goal 4. Reduce under 5 mortality by two thirds
Under 5 mortality rate (per 1,000) 35 21
Infant mortality rate (per 1,000 live births) 26 17
Measles immunization (proportion of 1 year old immunized, %) 82 88
Goal 5. Reduce maternal mortality by 3/4
Maternal mortality ratio (modeled estimate, per 100,000 live births) - 130
Births attended by skilled health staff (% of total) 82 96
Contraceptive prevalence (% of women ages 15 - 49) 66 78
Goal 6. Halt and begin to reverse the spread of HIV/AIDS and other major diseases
Prevalence of HIV (% of population ages 15 - 49) - 0.6
Incidence of tuberculosis (per 100,000 people) 63 45
Tuberculosis cases detected under DOTS (%) - 83
Goal 7. Halve the proportion of people without sustainable access to basic needs
Access to an improved water source (% of population) 92 93
Access to improved sanitation facilities (% of population) 82 86
Forest area (% of total land areas) 55.4 54.7
Nationally protected areas (% of total land areas) - 74.4
CO2 emmissions (metric tons per capita) 1.7 1.2
GDP per unit of energy use (constant 2005 PPP $ per Kg of oil equivalent) 7 9.2
Goal 8. Develop a global partnership for development
Telephone mainlines (per 100 people) 6.9 17.2
Mobile phone subscribers (per 100 people) 0 73.6
Internet users (per 100 people) 0 26.2
Personal computers (per 100 people) 0.9 5.5
Table 1. Value achieved in Colombia until 2008 according to the Millennium Development Goals.
Healthcare Related Statistics
Data Value
Access to an improved water source 93%
Access to improved sanitation facilities 86%
Mortality rate, infant 17 per 1,000 live births
Child malnutrition (children under 5) 5%
World Bank (2008)
Life expectancy at birth m/f (years) 73/80
Probability of dying under ﬁve 19 per 1,000 live births
Probability of dying between 15 and 60 years m/f 166/80 per 1,000 live births
Total expenditure on health per capita (PPP International $) 569
Total expenditure on health 6.4% of GDP
Global Health Observatory (2009)
Table 2. Healthcare related statistics according to the World Bank (2008) and the Global Health Observatory (2009).
Averageexchangerate(USD)
Figure 3. Colombian expenditure on healthcare (est. 2008).
Per Capita Annual Expenditure on Healthcare
1995
Colombia Region of the Americas’ average
2000 2005 2010
0K
1K
2K
3K
» 15% of population (approximately 6.9 million) are without medical insurance.
» Extreme low quality in health services provided to the poor.
» Poor infrastructure and shortage in public hospitals.
» High bureaucracy in accessing the public health system.
» Private insurance companies delay payment of treatments.
Main Problems of the System
Healthcare in Colombia

Caldas
Proﬁle
Caldas department is part of the Colombian Coffee Growing Axis with a total area of 7,291 km2. Caldas’ department
has a population of 976,438 inhabitants consisting mainly of 25-29 year olds. The combination of mortality rates and
migration of young people due to the scarcity in the labor markets is leading to an increment on the aging population
(40+ year olds).
Figure 7. The Caldas region.Figure 6. The Caldas population structure by large groups.
40 - 59
60+
0 - 17
18 - 39
34.1%
32.4%
22.4%
11.1%
2005
31.6%
32.6%
23.8%
12.0%
2009
29.3%
32.9%
23.6%
14.2%
2015
Although the matriculation at the Caldas universities in the ﬁeld of Sciences
of Health were of 3,285 students, and the medicine schools in Colombia
have increased from 21 to 54 in the last 20 years, doctors that graduate are
concentrated in the big cities making it difficult to achieve health coverage
for the entire population.
Figure 4. Estimated mortality causes for women (%) Colombia, 2004 Figure 5. Estimated mortality causes for men (%) Colombia, 2004
Hypertensive 3.8%
Ischemic heart 14.4%
Cerebrovascular 9.3%
Other CVD’s 5.3%
Lung 1.5%
Breast 2.5%
Colorectal 1.5%
Leukemia 1.0%
Lymphomas 0.9%
Stomach 2.9%
Circulatory
32.8%
Circulatory
21.2%
Cancers
11.5%
Other causes
13.8%
Cancers 19.9%
Other causes
15.3%
Injuries
7.6%
Injuries
38.0%
Other NCD’s
12.2%
Other Cancers
9.6%
Respiratory
6.7%
Diabetes
5.5%
Diabetes 2.5%
Hypertensive 2.1%
Respiratory 4.9%
Ischemic heart 11.3%
Cerebrovascular 4.7%
Other NCD’s 8.2%
Other CVD’s 3.0%
All NCD’s
77.1%
All NCD’s
48.2%
The average income of a general doctor in Colombia
is around $285 (3-4 minimum wages). Around 8% of the
doctors are unemployed and 5% work in different jobs.

Scarcity in the labor market, added to the great reduction in
agricultural production have conspired to create higher rates of
inactivity and greatly increase the chances of falling into poverty.
Out of the total
Caldas population...
It means that 3 out of every
5 inhabitants of Caldas are
poor by definition
25.7% are registered as
SISBEN Level 1 (extreme poverty)
SISBEN Level 2 (poor)
SISBEN Level 3
The SISBEN Level *SISBEN: The Selection System of Beneficiaries for Social Programs is a social survey done by the government, to rank poor people
(from economical strata 1 and 2) according to their quality of life. People are divided in three categories: 1, 2 and 3 (where 1 is the
lowest quality of life). SISBEN is used to select people for social assistance programs from the government, who have “... a state of
deprivation not only in material welfare (food, housing, education, health, etc.) but (…) also personal and property uncertainty,
vulnerability to health, disasters and economic crisis, social exclusion and political life and liberty of making abilities”.
The average size of a household
according to SISBEN level in Caldas 4.5Level 1
4.0Level 2
3.4Level 3
174,142
31% are single moms
17,832
36% are single moms
7,510
36% are single moms
Number of households as registered by SISBEN
Is the inactivity rate
in the region of Caldas
Is the inadequate employment rate
due to income in the Caldas region.

Villamaría
Proﬁle
Villamaría is a municipality of the Caldas Region and is situated 9 km away from the capital, Manizales. It has an area of 461 km2 and
a population of 50,123 inhabitants.
Caldas population
± 1,000,000
Manizales population
± 387,000
Villamaría population
± 50,000
Healthcare Professionals in Villamaría
In 2009 Villamaria had Colombia had
1 doctor for every 2,083 inhabitants 1 doctor for every 740 inhabitants
1 dentist for every 4,545 inhabitants 1 dentist for every 1,282 inhabitants
1 nurse for every 8,333 inhabitants 1 nurse for every 1,818 inhabitants
Table 3. Number of healthcare professionals in Villamaria compared to the whole Colombia in 2009.

Benchmarks
Mothers Club, Kendubay
Sub-District Hospital
CFW
Shops Kenya
SOS
Médcins France
Distance Healthcare
Advancement - DISHA ASEMBIS
Pre natal/delivery care and education
The club recruits women attending the hospital’s pre-
natal clinic. The women are asked to make a commitment
to deliver their next child in the hospital and meet as
a group twice a month to receive health education,
including training on safe motherhood practices.
Other than that, they are asked to take an active role
in educating other women in their villages about safe
motherhood and the risks of delivering at home.
Key point: Empowering and integrating local
women in the healthcare delivery model through
an educational role.
Affordable healthcare franchise model
A network of 64 financially self–sustainable centers
that deliver government approved health products and
pharmaceuticals at $0.50 per treatment. Distributed in
urban, rural and semi-rural areas, these units are located
within an hour distance from their intended customer
base and serve more than 400,000 Kenyans a year. More
than half of the locations are owned by community
health workers while the rest is owned by licensed nurses
which also provide screening services. The quality of the
services is guaranteed by unannounced audits and the
threat of the closure. In exchange, they bear a brand
name, share marketing costs, best practices and benefit
from a centralized buying platform.
Key point: Creating a replicable and affordable
model that benefits from group synergy and local
entrepreneurs.
Mobile healthcare
The concept is simple: patients in need of care can
contact a call center 24 hours a day, 365 days a year that
finds an available doctor and sends him to their home,
much like a taxi business. A success that counts with a
thousand emergency doctors and 62 associations spread
over the territory, and have handled so far 4 million calls
and 2.5 million home interventions and consultations;
60% of procedures performed at night, Saturday
afternoon, Sunday and holidays. The achieved results are
a consequence of the reliability and unfailing motivation
of the key players.
Key point: Providing alternative channels for care
delivery through an extremely flexible organizational
model.
Mobile healthcare and partnerships
The goal of DISHA is to deliver high-quality, low-cost
diagnosis and care to low-income rural communities that
are not addressed by the existing healthcare system
through a mobile tele-clinical van. In this initiative,
Philips, an imaging and medical diagnostics company,
partnered with a government agency (ISRO) that provides
satellite connectivity between the van and the hospital,
Apollo, the healthcare service provider which will staff
the van, and a local NGO.
Key point: Creating alternative channels to deliver
healthcare and create synergetic partnerships.
Discounted medical services
Through the use of a multi-tiered pricing model,
ASEMBIS has created a financially self-sustained network
of eye care clinics that offer services from basic eye
examinations to sophisticated surgical procedures at a
40-70% discount from the market rate. Its integrated
network includes non-traditional health professionals
for vision testing and preventive care, cost-efficient and
high-volume clinics, and mobile rural clinics; an overall
treating of more than 350,000 patients in 2004. The 8
clinics in different regions of Costa Rica, offer nationwide
coverage, and provide a wide spectrum of medical
services, from basic health to sophisticated surgeries,
imaging diagnostics, and almost all specialties.
Key point: Creating a network of financially
sustainable healthcare clinics that offer
specialist services and uses alternative
professionals to deliver care.
Many solutions have been implemented throughout the world to improve healthcare access to low income communities.
We looked into some of the different approaches to get inspiration for our concept.

Project Goal:
Improve access to primary
healthcare in Caldas, by
redesigning the existing
Bienestar social business model,
in order to expand and replicate
it in Colombia and possibly
elsewhere.

Observation
& Synthesis

The Field Research in Caldas, Colombia
A substantial part of the input gathered for this project comes from the field research conducted in Caldas, Colombia
from May 15th to June 5th, 2011. Our stay was supported by the local organizations Grameen Caldas and Bienestar,
which helped us individuate and contact the local players, make the arrangements for the activities and guide us on
field.
This phase of the project was based on qualitative research methods which, combined with the desktop research,
helped us in getting a complete overview of the situation and arriving to the desired solution.
“At the early stages of the process, research is generative—used to inspire imagination and inform intuition about
new opportunities and ideas. In later phases, these methods can be evaluative—used to learn quickly about people’s
response to ideas and proposed solutions”. (IDEO Toolkit).
The Research Tools
The Colombian Healthcare System
Design tools used with the different stakeholders
Tools Stakeholders Goals
Group interview Doctors, medical
professors and students
from Manizales University.
Understanding the complexity of the Colombian healthcare
system, its stakeholders, how they are connected to each
other and their influence on the system.
Discovering the main touch points of the existing healthcare
service and tracing money, time and information flow.
Understanding the perspective of doctors, their aspirations
and frustrations.
Discussion sessions Grameen Caldas team and
Bienestar founders.
Understanding the Holistic Social Business Movement in
Caldas and its goals, as well as the criteria for accessing the
fund assigned by the Government to finance social businesses
in Caldas.
Understanding and analyzing the first outcomes, limitations
and challenges of Bienestar social business pilot phase.
Individual interviews Patients, community
workers and healthcare
related players such
as doctors, nurses and
pharmacists.
Understanding the person.
Understanding the general healthcare and medical experiences
of users.
Understanding the specific experiences related to user profile.
Different Regimens Within the Colombian Healthcare System
Regimen Description Affiliations in
Colombia
millions / %
Affiliations in
Villamaría
millions / %
Contributive
(RC)
People with employment contract or independent workers who earn at least two minimum salaries per month are affiliated
to the contributive regime; they have to pay a monthly affiliation to an EPS (12.5% of their monthly wage); 8.5% is paid
by employers and 4% is paid by employees, and they should pay moderating fees ‘copays’ established in the POS for the
contributive regime.
17.3
(39%)
16.5
(33%)
Subsidized
(RS)
Unemployed people and people from SISBEN 1 and 2, likewise their family; they should pay moderating fees established in
the POS for the subsidized regime according to their SISBEN level. Of the 12.5% total contribution per individual of the RC,
the FOSYGA channels 1.5% into the RS as a solidarity contribution.
23.8
(51%)
15.9
(32%)
Not affiliated
(Vinculados)
People who are not classified by the SISBEN and don’t have access to the subsidized healthcare services, as well as SISBEN 3
and independent workers with payment capacities. They are covered by the PBS. This plan is a safety net financed by general
taxes that is composed of public hospitals and health centers. While all citizens are eligible to receive the benefits under
this plan, it primarily serves those who have not yet been enrolled in either the RC or the RS and those who are enrolled in
the RS but require services that are not yet covered under its benefits package.
4.2
(8%)
17.5
(35%)
Special
(RE)
People who work for the government, armed forces and teachers of public institutions; this plan is financed by the
government and they benefit from their own network of healthcare providers and have very few limitations on the services
provided.
1.2
(2%)
N/A
Table 6. Definitions of the different regimens within the Colombian healthcare system.
Table 4. Description of the design tools used with the different stakeholders.
To understand the complexity of the healthcare system, it is important to look into its institutions, the different forms
of coverage it provides to the population and the regulations behind it.
The public healthcare is regulated by the law 100/1993, which established the SGSSS (General System of Social
Security in Health). This system is coordinated, directed and controlled by the state and the funds designated by the
government are managed by the FOSYGA (Fund of Solidarity and Guarantees).
The main healthcare institutions involved in delivering healthcare services to the population are the EPS’ (Health
Insurance Companies) and the IPS’ (Health Service Providers).
The EPS functions as an intermediary between its affiliates and care delivery institutions (IPS) in managing
appointments, approvals and the payments of health services. It has to guarantee to its affiliates the minimum
established by the POS (Mandatory Health Plan), which is a list of treatments, procedures and drugs defined by the
government.
The IPS is a public or private entity that provides medical procedures. IPS’ are divided in 3 levels of attention and the
vast majority only cover the first level.
The quality and coverage of health services are directly linked to the affiliation of the patient to the system. There are
four types of regimens:
List of Acronyms
Initials Name in Spanish (English)
SGSSS Sistema General de Seguridad Social en Salud
(General System of Social Security in Health)
EPS Entidades Promotoras de Salud
(Health Insurance Companies)
EPS-S Entidades Promotoras de Salud Subsidiadas
(Subsidized Health Insurance Companies)
IPS Instituciones Prestadoras de Servicios de
Salud
(Healthcare Providing Institutions)
POS Plan Obligatorio de Salud
(Compulsory Healthcare Plan)
FOSYGA Fondo de Solidaridad y Garantía
(Fund of Solidarity and Guarantees)
PBS Plan Basico de Salud
(Basic Health Plan)
Table 5. Acronyms of the Colombian healthcare system.

Moreover, the access to generic essential drugs (from a list of 350 medicines) is covered through the POS for those
under the contributive regime and with certain restrictions for those under the subsidized regime.
For those not covered by the system, there is almost no access to any medications at all, since this is strictly limited to
primary care medications that do not exceed a value of USD$4.
Therefore, it is clear that the population that lacks the most access to adequate healthcare is the one not afﬁliated to
the system (vinculados) followed by the subsidized regimen. Combined they represent 67% (34,000) of the population
of Vilamaria—against 59% in Colombia. Vinculados alone, represent 35% of the population in Villamaria, amounting to
a total of 17,500 people without health coverage.
Public Healthcare System Map

The network of care providers in Villamaria counts with 5 IPS’ (Table 7) of which only one is a public provider.
It is also the only one that provides emergency and delivery services. The other entities are private and offer only
prevention, promotion and consultation services. For second and third level care, patients have to go to Manizales or
Pereira.
Unless it is an emergency, the affiliated patients have to pass through their assigned EPS for approval and scheduling
of appointments, a process that often delays the treatment to several weeks and sometimes even months.
For Vinculados, the process could seem more direct, but services offered in the public IPS are very limited, waiting
time is huge and insufficient resources lead to very scarce services.
Briefly, EPS’ and IPS’ are the main players with the biggest influence in the system and on the final care received by
the population. The following graph describes the role of each stakeholder in the system and compares their level of
influence and power.
Patients have little control and decision power which leaves them without much influence within the system. Moreover,
doctors and healthcare personnel are subject to IPS´ rules and constraints and to the lack of proper job conditions,
a cause for poor motivation and professional fulfillment. Imposed POS limitations together with inadequate in-house
resources are not only a frequent source for their frustrations but a barrier to a proper care service for the patients.
Healthcare Service Providers in Villamaría
Entity Public /
Private
Level of
complexity
Patients
treated
(2009)
Assistant
Staff
Admin.
staff
Hospital San Antonio Public I Level 41,173 55 34
Centro Médico El Parque Private I Level 19,540 6 3
Salud Total Private I Level N.A. 6 1
S.O.S Private I Level 6,803 6 1
Pasbisalud Private I Level 16,383 13 0
Table 7. Description of the healthcare service providers in Villamaria.
EPS’
(healthcare insurance companies)
Don’t provide any medical service, but work as an intermediate between their members and
the affiliated IPS’. Manage the money flow between the two.
State / Admin Coordinates, directs and controls the public health system (regimen affiliations, EPS’ and
IPS’ regulation and POS limitations). Directly finances life-threatening cases outside of the
POS (tutela).
IPS’
(health service providers)
Hospitals, clinics, laboratories. Manage and provide healthcare personnel, infrastructure and
supplies for care delivery according to the POS coverage and to the patients’ EPS affiliation.
Private IPS’ are paid by EPS’. Public IPS’ are for non-affiliated patients (vinculados).
Doctors and Health
Personnel
Hired by the IPS’ to deliver medical services.
In general, they are not able to deliver adequate care since they are limited by their IPS’
and the POS.
Patients Access to treatments, exams and medicines, as well as services copays, depend on
their regimen affiliation (contributivo/subsidiado) or lack of it (vinculado), and to POS
limitations. Often receive inadequate medical services, have no influence in the system and
are subject to EPS decisions.
Pharmacies Sell medicines and provide health counselling. They are often used as an alternative access
point to healthcare, but don’t have any actual medical power.
IPS Pharmacies Give or sell prescribed medicines according to insurance coverage of the patient treated in
the IPS.
Stakeholders of the Public Healthcare System
Influence on the System
EPS’ and IPS’ are the main players
with the biggest influence on the
system and on the final care received
by the population.

Bienestar
Bienestar was initiated in 2010 as an alternative healthcare service to the public health system. Based on the Ser
model in Argentina, Bienestar´s mission is to improve the access to primary healthcare services for low income
communities in the Caldas region, following the social business principles.
The main idea behind Bienestar is to eliminate the barriers imposed by the EPS’ by selling membership cards that link
members directly to the affiliated clinics. For USD$5 a year, the cardholder is entitled to discounts up to 50% on the
treatments delivered by the network. The map on the opposite page illustrates how the Bienestar system works.
The model aims to empower patients and to cut the bureaucracy imposed by EPS’. The patients get a better services
and the waiting time is reduced. In exchange, affiliated clinics win by increasing the volume of patients and by having
instant cash — EPS usually take months to pay the contracted services.
The project during our research was in its pilot phase, with one affiliated clinic and 90 members in Villamaria.
The map shows some advantages of this stage of the project by eliminating EPS´ authority and by increasing the
influence of patients on the scale. However, the situation is still not the ideal since the care quality cannot be
guaranteed because the affiliated clinics are still managed in the same way as before entering the network.
SER System Model
CEGIN is a medical center founded in 1989 which specializes in the provision of medical services to poor women
from rural areas of the Jujuy Province. Jorge Gronda launched the SER system within the CEGIN center in 2004. It is
a membership card that patients can purchase for USD$3 per year in exchange of preferential rates (more than half
of the market price) on services delivered in these centers. The main idea behind the SER card, beyond increasing
access to healthcare, is to create a network that will later allow its members to enjoy various advantages. Currently,
card holders already enjoy discounts in some pharmacies, and in the long term, his ambition is to develop a system of
“social franchise”, and extend the SER cards’ field of action to various fields such as food, construction and transports.
The social impact of CEGIN and the SER system allow the people at the base of the pyramid to have access to quality
healthcare. Nowadays, over 40,000 people are followed by these clinics (including 20,000 through the SER network).
Belonging to the SER networks and enjoying quality care services considerably increases the self-esteem of people
suffering from social exclusion. The pride SER clients take in being part of the network makes them talk positively
about it, and this word of mouth has been fundamental in the development of CEGIN.
Table 8. Description of the SER system running in Argentina.
Bienestar System Map

As the last part of our field research, we did a series of interviews with different stakeholders of the system, with a
special focus on the final user, the patient. Our aim was to understand their concerns, expectations and frustrations,
as well as listen to their experiences in order to develop a user-centered solution.
By interviewing doctors (working in the public system and in the Bienestar affiliated clinic), medicine students, the
Bienestar affiliated clinic owner, a nurse, a pharmacist, a social worker and an EPS customer representative, we took
into consideration all the different points of view, an important step in developing the further service. Interviews took
place at people’s houses, around the community, at a pharmacy, a local medicine market, a 2nd level public hospital in
Manizales and at the Bienestar affiliated clinic, El Parque.
IPS
(Bienestar-affiliated clinics)
Manages and provides discounted health services direct to Bienestar members, in exchange
for a bigger volume of patients. Maintais its role in the public health system. Ensures
appropriate infrastructure, personnel and supplies to provide the care.
Doctors &
Healthcare Personnel
Hired by the IPS to deliver medical services.
They are able to deliver better care, since they are not limited by the POS anymore, but are
still limited by their IPS.
Bienestar Links patients and Bienestar-affiliated IPS’ through the sale of a membership card that
entitles to discounted health services. An alternative to the actual primary healthcare
system, it cuts the access barriers imposed by the EPS’ and the POS.
Patients
(Bienestar members)
Hired by the IPS’ to deliver medical services.
In general, they are not able to deliver adequate care since they are limited by their IPS’
and the POS.
Pharmacies
(Bienestar affiliated)
Sell medicines discounted by 5% to Bienestar patients in exchange for a bigger volume of
sales.
State / Government Regulation and autorization of Bienestar activities.
EPS’
(health insurance companies)
Address the patients to different healthcare providers (IPS’) when Bienestar does not cover
the request (specialists, exams).
Stakeholders of the Bienestar System
Interview Guides - Patients
Name Gender Age Occupation Household Structure Household Income
Bienestar
User
Sisben Level
Insurance
Regimen
Maria Elsita Mayo Female 50 Years Housewife Lives with husband and 2 of
their 5 kids (10yrs twins)
No Sisben 2 Subsidiado
Nestor Ivan Garcia Male 41 Years Informal
construction
worker
Lives with wife and stepson
next door to his family in
law
Income depends on
couple’s job
Yes Sisben 1 Subsidiado
Gloria Bettancourt Female 50 Years Unemployed Lives with husband, her
mother and their 4 kids
Income comes from
husband’s job
Yes Sisben 1 Subsidiado
Paula Hernandez Female 29 Years Works at a call
center at night
(her mother
takes care of her
daughters)
Lives with husband (works
during the day) and their 2
daughters (10yrs + 4yrs)
Income depends on
couple’s job
Yes Sisben 1 Contributivo
Ober Osorio Male 78 Years Retired
policeman
Lives with his daughter Pension No Sisben 2 Regime
especial
Gloria Ines Female 48 Years Unemployed Lives with husband, their 3
sons and 1 nephew
Income depends
on husband’s job
who works in
construction
Albaneli Franco Female 40 Years Housewife Single mother, lives with
son (7yrs), mother, 4
brothers and 1 nephew
Income is based
on the jobs of the
brothers and sister
Yes
(+2 family
members)
Sisben 2 Subsidiado
Lina Paula Ospina Female 23 Years Unemployed Single mom, lives with her
two kids (7months + 3yrs)
and her grandparents
Income depends on
her father
Table 9. Patients’ profiles from the interviews in Villamaria.
The Interview Guides

Table 15. Example of an interview guide used during the field research in Villamaría.
Interview Guides - Social Worker
Name Gender Age Occupation
Yurdani Woman 28 years Social worker at the Municipality of Villamaria**
** takes care of social and cultural programs with the local youth (14yrs – 26th)
Table 14. Social Worker’s profile from the interviews in Villamaria.
Interview Guide - Female Patient
1.
Understanding the person
» What is your name, age, marital status, number of children, parents...?
» Where are you originally from? If not Caldas, where from and why did you move here?
» Who do you live with? Are all your children living with you or did any leave? Do your parents live with you? Why?
» What do you do for a living? And the other members of your family?
» Are you the only person contributing for bringing money home? If not, who else?
» Do you work outside your house? If so, do you work close to you home? How do you get there?
» What forms of transportation do you use?
» Are you a frequent user of medicines? If yes, what medicine do you use and for what health problem?
» Do you or anyone from your family suffer from any chronic or hereditary disease? (heart disease, stroke, cancer, chronic respiratory diseases and diabetes...)
2.
Understanding the general
healthcare & medical
experiences of user
On the Colombian healthcare system
(how they see it, service, time to get
treatment, difference with Bienestar).
» Have you used the public healthcare system?
» Did you feel well attended? How did they treat you?
» How much money from your salary goes to the public system?
» How do you regard public healthcare? What is your opinion?
» How long did it take you to get treated?
» Where did you have to go?
Before going to the doctor - look for
alternative ways.
» Do you go to the pharmacist sometimes for medical advice?
» When feeling sick you try to talk with someone about it? Do you consult family members, friends, other sources?
» What kind of illnesses do you feel you can solve without a doctor? How would you do it?
» What medicines do you always have in your house? Where do you keep them, can you show me?
» What remedies do you always have in your house? Where do you keep them, can you show me?
» Do you have a first aid kit? Can you show it to me?
» Do you use alternative ways of treatment (infusions, teas, ungüentos)?
» Can you describe an experience related to any of these issues that have happened to you or somebody that you know?
Going to the doctor (motivation,
decision making, education).
» What kind of prevention do you take? (hygiene, nutrition, chlorine in water, iodized salt, etc.)
» How often do you visit a doctor?
» When do you feel you need to go to the doctor? How ill do you need to be?
» What makes you decide against visiting a doctor when a health problem occurs?
» Where is your nearest healthcare center/doctor? How long does it take you to get there?
» How do you go to the doctor’s clinic? Do you use public transportation (bus, taxi, chiva, etc)?
» What do you do when there is an emergency?
» Do you take the decisions regarding health condition of others in your family?
» Do you usually go accompanied to the doctor? If so, is it a family member, a friend? What family member? (child, husband)
» Do you save some part of your budget for health emergencies?
» Is it a problem with your employer to take time off from work if you need to see a doctor?
Doctor - visit » How is your relationship with your doctor? Describe it in some words.
» Where do you go to visit your doctor (clinic/hospital)?
» When going to the doctor, do you feel that you are paying too much/enough for his services?
» How many times more or less do you go to the doctor per month, per year?
3.
Understanding the specific
healthcare experiences
related to user profile
Doctor / clinic experience » Do you trust doctors?
» Do you have a trusted doctor that you always go to or wish you could always go to?
» Do you prefer a male or a female doctor?
» List some characteristics that you think are very important in a service. What do you appreciate most in a visit?
» What is your opinion about nurses, assistants, other staff?
Women » Did you see a doctor on regular basis when you were pregnant?
» Where did you give birth? Who helped you in giving birth?
» How often do you take your children to the doctor?
» Are you aware of regular checkups like Papanicolao? If so, do you have them?
Bienestar user » Why did you choose Bienestar? Do you think the healthcare service has improved with Bienestar?
» What determined you to enter Bienestar program?
» Have you advised someone else to use it?
» Do you have a trusted doctor that you always go to, or wish you could always go to? Is he from Bienestar?
» Did you notice something different (service experience) using Bienestar from your past experience?
» What are your expectations from Bienestar?
Not Bienestar user » Have you ever looked for private insurances regarding healthcare?
» Do you know what an insurance is? Have you ever considered it?
» What determined you to enter Bienestar program?
Interview Guides - Nurse
Bienestar
User
Sisben Level
Insurance
Regimen
Eluin Osorio Female 46 years Works at Nueva EPS Lives with son (21yrs), his
wife and grandson (2yrs)
Income depends
only on her job
No Sisben 2 Contributivo
Table 11. Nurse’s profile from the interviews in Villamaria.
Interview Guides - EPS User Representative
Bienestar
User
Sisben Level
Insurance
Regimen
Doralba Seballos
Mosqueiro
Female 64 Years President of
the association
of Villamaria’s
Caprecon (EPS)
users*
Lives on her own Government help to
the 3rd age citzens
* in charge of gathering the complaints from Caprecon users in Villamaria to take them to the Manizales Health Superintendence.
Table 10. EPS User Rappresentative’s profile from the interviews in Villamaria.
Interview Guides - Doctors
German Aristizabal Moreno (Bienestar) Male 45 years Works at and owns Centro Medico El Parque
(a Bienestar affiliated clinic), certified as a general practitioner
Adrian Zapata Male 32 years Works at Centro-Piloto Bas Salud (2nd level public hospital in Manizales)
Table 12. Doctor’s profile from the interviews in Villamaria.
Interview Guides - Pharmacist
Berta Female 75 years Works in her own pharmacy with her daughter
Table 13. Pharmacist’s profile from the interview in Villamaria.

“Doctors become
insensible”.
Maria Elsita Mayo
50yrs. Patient
“For the health, I don’t
think twice, I pay”.
Nestor Ivan García
41yrs. Patient
“I don’t have a place
where to send the
children”.
Adrian Zapata
32yrs. Doctor
Paula Hernández.
The difficulties of dealing with the EPS’.
Paula Hernández, 29 years, is originally from Manizales. She moved to Villamaría with
her mom that now lives in a different house.
She rents a house in one of the neighborhoods in Vallamaría where she lives with her
new husband and her two daughters from her previous marriage. She works during the
night for a mobile phone company and therefore sleeps during the day. Paula’s mother
takes care of the two children and some of the domestic chores as Paula rests during the
day.
One of her daughters, Paola, is 5 years old and was born with a malnutrition problem
that led to an orthopedic issue making it difficult for her to walk. This has caused Paula
to face many difficulties in trying to access the right treatment ever since Paola was
born.
During her pregnancy, Paula was diagnosed with a morphological problem that made it
difficult for her to give birth. That is why she blames herself and feels responsible for
her daughter’s complication.
Paula has been trying to schedule the necessary surgery but she has not been able to do
so. Due to the bureaucracy within the system and the long time required, she has been
struggling to fix a surgery since Paola’s problem can only be solved at a young age.
Every time Paola needs a treatment, she has to go through a general doctor that then
sends her to a pediatrician and finally to a pediatric orthopedist in order to get the
treatments approved and done.
“I lose a lot of time”. Paula said. Whenever she books an appointment through her EPS,
she usually waits from 15 to 20 days for confirmation without having the possibility to
choose neither the doctor nor the hospital she has to go to.
She enrolled Paola in the Bienestar plan as she was desperate to find a solution for her
daugher’s problem. Ever since then, she has been very satisfied. “Now the doctor really
takes care of her and gives me advice on what to do”. Before, she felt that the doctors and
nurses of the public system did not really care about her daughter nor her illness.
She would like all her family members to sign up for the Bienestar plan, especially her
mother who is also sick. Paula’s mother helps her a lot in raising her daughters and does
not have any kind of healthcare coverage herself, but the income inside the house only
allows them to have Paola insured.
Her two daughters represent her major priority, that is why even if she is enrolled in an
EPS she chose to pay extra and take better care of both of them.
“The EPS meetings
with the users
happen once a
month. Nonetheless,
very few people
attend them”.
Doralba Seballos Montero
64yrs. EPS representative

To synthesize the information gathered during the interviews, we created personas based on the different family
structures in Caldas. They represent a general profile of the Colombian reality.
The Interview Guides - Personas
Persona 01 - Margarita Perez
Sex: Female
Age: 23 years old
Sisben: Level 1
EPS: Caprecom
(subsidised)
Margarita is unemployed and lives with her grandparents, Sofia and Pedro. Her 26 year old partner, Miguel, lives with them and they have 2
children together. One of the children is 3 years old and the other is 3 months old.
Miguel is a construction worker and the source of income to support the children.
Margarita’s grandfather:
Pedro suffers from ulcer, hernia, prostate, high blood pressure and had the Cafe Salud EPS, which he was denied from because of his many chronic
illnesses. He hates going to the doctor and Sofia and Margarita are always finding ways to trick him into taking him there. They had to pay 3,000
pesos for the card when enrolled in EPS and a fine of 8,000 pesos whenever they didn’t show up to an IPS visit. Tutella accepted his request but
takes a long time (3 months) to get appointments.
Margarita has mastitis (breast milk problems) and goes to the pharmacy instead of the doctor since the doctor is always changing and the
checkup time is too short. She would like to study to be a nurse one day. Margarita and Sofia are the decision makers in the house.

Persona 02 - Pablo Salazar
Sex: Male
Age: 41 years old
Sisben: Level 1
EPS: Caprecom
(subsidised)
Paco is a construction worker on freelance terms. He is living with his partner, Angelica, who has a son from a previous relationship. Their house
is close to Angelica’s parents’ house who live together with their other daughter and her 2 children.
Paco is the income provider of the family. He has a lump in his hand but has never had it checked. He has had previous bad experiences with a
doctor where he was given the wrong prescription for a disease in addition to always waiting too long to get a consultation.
He enrolled in Bienestar but hasn’t used it yet. He is willing to pay a little bit more to ensure healthcare access in case of emergency.
“In health matters, I don’t think twice, I pay”.

Persona 03 - Maria Gonzalez
Sex: Female
Age: 28 years old
Sisben: Level 1
EPS: Salud Total
(contributivo)
Maria and her children live with Franco, Maria’s husband and the children’s stepfather. She works at night in a call center and her husband works
at Gommaz. They rent a house which is close to Maria’s parents’ house so her mother can take care of the children while Maria sleeps during the
day.
Maria has 2 daughters:
»» Gloria, 5 years old, suffering from malnutrition
»» Mailin, 7 years old, who had apendicitis
Maria’s daughter:
Gloria goes to a nutrionist which EPS covers but Maria enrolled her into Bienestar so she can have fast access in case of an emergency and also
because they get a sense of attention from the doctor which isn’t present with the doctors EPS assigns.
Maria’s mother:
Fernanda is 50 years old and suffers from uterine cancer, hypertension and cholesterol. Her EPS is with Caprecom (subsidised). She takes care of
her husband, Ramon, who is unemployed and sick, and her grandchildren by preparing their meals and accompanying them to school.
Maria is the decision maker in the family and takes care of the household between working and sleeping. She has no access to doctors and feels
she loses time and money with doctor visits as they don’t giver her the attention needed. For her children’s vaccinations, she has to take care of
the appointments and followups herself.

Low Income Colombian Family Structure

Identification of Problems & Needs
To understand the weaknesses and opportunities, we made a list of all the problems and needs of each stakeholder
based on the following criteria: time, money, quality and bureaucracy.
From this point, we were able to identify the key success factors (KSF) to achieve a desired solution.
After that, we individuated the problems and needs that were addressed by Bienestar and the KSF’s that were taken
into consideration by the model. In table 16, the issues addressed by Bienestar are highlighted in green.
Going through the synthesis process, we were able to identify several common problems and needs.
We realized that the Colombian family structure represents a pillar for developing a solution that would take into
consideration the urgent need of convergence of all different plans within the same household.
Due to the fact that the EPS is assigned by the working position, individuals cannot choose their personal plan. Many
people are not even covered by any EPS because of several bureaucratic and registration problems during the phases in
between changing jobs. This situation generates a massive dependency on the other family members, particularly from
an economical point of view.
During the interviews we also found out about the existence of a basic mistrust towards doctors, blamed for being
more attentive to the bureaucratic aspect of their work rather than the health problems of their patients. This feeling
contributes to the lack of continuity between patient and doctor relationships and leads to an impersonal, superficial
and frustrating environment. For example, the figure of the general practitioner (GP) is being replaced by that of the
pharmacist because of an easier access and unpleasant past experiences. In this way, pharmacies are becoming the first
point of consultation.
Apart from offering a faster and easier access to healthcare, now missing due to all the misconnections and
bureaucratic aspects, it is important to build a continuous relationship between the patient and the doctor.
At the end of the analysis, it is clear that many areas of opportunities coexist in the Colombian healthcare system, and
that different solutions would be able to solve one or more problems.
Bienestar’s pilot trespasses some of the bureaucratic aspects to access primary care through the elimination of the
EPS´ role. Nevertheless, it still cannot fully guarantee the quality of the services delivered by the affiliated health
institutions, since no changes have been implemented by any affiliated clinics.
Problems, Needs & Key Success Factors
Problems Time Money Quality Bureaucracy
Patients Family members within one household belong to different EPS healthcare plans X
Patients cannot choose their own EPS (assigned to them by system) X
Many people are not covered by any EPS X
Family members rely on relatives to cover healthcare expenses X
No continuity of patient/doctor relationship X
Doctors cannot dedicate sufficient time to patients because of system and bureaucracy X
Long waiting time in EPS queue to get doctor appointments X X
Long waiting time inside IPS to get diagnosed X X
Long waiting time for EPS approval of treatment X X
Some treatments are denied by EPS when not belonging to POS (plan obligatorio de salud) X X
Patients need to pay a fine if they do not show up at the assigned IPS X X
Patients have to cover travel expenses to reach assigned IPS X X X
Patients are not properly informed about their medical conditions X
Patients don’t trust the doctors X
Patients are not aware of the system and its procedures nor their personal rights X X
Patients lack knowledge and awareness on prevention methods X
Patients have no access to their medical records X X
Doctors Doctors are not able to prescribe adequate treatments due to POS limitations X X
Doctors are replaced with pharmacists since they are more accessible to patients X X
Doctors have no access to patient medical records X
Lack of access to specialist treatments inside the public health system X X
Clinics Lack of infrastructure in IPS to accommodate for volume of patients X X
IPS are not able to manage their resources/lack of resources to provide quality service to clients X
No way of receiving feedback/complaints from patients X
Needs Time Money Quality Bureaucracy
Patients Easier access of all family members within household to the same health plan X X
Information about personal health condition X
Reduce waiting (wasted) time through process X
Trust in doctors for appropriate treatment and followup X
Affordable visit and treatment expenses X
Access to specialized treatments X
Doctors Access to updated patient clinical history X
Gain the trust of patients X
Allocation of time for proper and complete diagnosis of patient X X
Ability to prescribe the appropriate treatment for the specific patient condition (independent of POS) X
Ability to follow up on patients’ progress and well being X
Clinics Capability to manage patient overflow X X
Optimize resources in order to deliver appropriate services X
Keep track of patients’ clinical history X X
Provide a better communication channel between patients and doctors X
Key Success Factors Time Money Quality Bureaucracy
Patients,
Doctors,
Clinics
Equal accessibility to health care for all family members within household X
Up-to-date patient database system X X
Different health services that generate an accessible Medical Network X X
Time efficient healthcare service X
Affordable primary healthcare visits and treatments for different patient conditions X X
Friendly and trustful relationship between patients and doctors X
Effective treatments for all patients X
Follow up and feedback from patient to measure outcomes for further service improvement X
Table 16. Problems, Needs and Key Success Factors identified during the field research in Villamaría, Caldas.

Bienestar
Familia
Concept

Bienestar Familia is a concept that is built around the specific family structure of Colombia. Starting from
the direct family living within one household, Bienestar Familia extends to encompass all members of the
community, the ‘larger family.’ Value Proposition
Our mission is to deliver quality and affordable family centered healthcare involving the
community in the value chain. Our concept is divided into two main parts:
This part of the concept consists in improving the primary healthcare experience of the
family through an unified health plan that covers all the members within a household
and gives them access to affordable services in Bienestar Familia clinics and network of
affiliated services. The family plan also entitles each family to a family doctor, ensuring
continuity and trust throughout the care delivery.
Based on the fact that different households have different needs, we wanted to make
our offer more flexible by creating a set of scalable memberships that adapt to the
specific family structures and are affordable to all family members.
This holistic family approach will offer a welcome family kit - with basic instructions on
the plan and its services and benefits - and a family check up for free as an introduction
to Bienestar Familia and to the assigned family doctor. The database will combine the
family data easing the access to family health records, reducing the time spent on
paperwork and ensuring the effectiveness of the treatment. Moreover, pediatricians will
be available for the children, who are often left unattended, and internists for those
who suffer from chronic diseases, one of the major health problems of the area.
The service will be complemented with family oriented initiatives in prevention and
education, such as family planning, pre-natal assistance and family counseling.
The community becomes an important link in the value chain of Bienestar Familia. As
mentioned before, it is important to use a participatory approach to gather consensus
and acceptance for the new business, especially in low income areas where relationships
inside the community are very strong.
This role will be filled by women chosen among the social business members and trained
by Bienestar Familia. The main target will be single moms and unemployed housewives
wanting to complement the family income. Creating job opportunities and empowering
women in the community will leverage the value of the model, while simultaneously
increasing their self esteem and feeling of belonging. The fairies will be the main point
of sale of Bienestar Familia memberships. A successful enrolment will be the start of the
fairy-patient relationship.
Each fairy will represent a group of families enrolled in BF. They will collect feedback,
guide users inside the Colombian healthcare system whenever treatments are not
delivered by Bienestar Familia - tutela requests, EPS approval - deliver prevention
and education, focusing on each family’s specific needs (e.g. infant nutrition, family
planning, etc) and help individuating patients in financial problems.
Most of all, the Fairies will be a key resource to make the services more responsive and
sensitive to the needs of its users, thus helping Bienestar Familia’s business model
to evolve accordingly. Moreover, when the model matures and starts expanding, they
can become an important channel of sales and distribution of products from partner
companies, such as pharmaceuticals or microcredit.
Fairies are autonomous and benefit from flexible hours to accommodate the single
mothers’ and housewive’s needs. They will work for a commission of the sales and
healthcare benefits for their family.
Ideally, fairy meetings with BF members would happen every month at the clinic. These
meetings can be used for co-creation sessions where unmet community needs are
individuated, as well as for target initiatives on education and prevention delivery.
The Family Healthcare Plan and
The Family Doctor
The Community Link:
Fairy (Health Promoters)

Bienestar Familia System Map
The main touch point of care delivery for Bienestar Familia will be its own healthcare
clinic. We believe that this is an important step, since in Villamaria there is a deficiency
of delivery points (IPS’) and doctors working on them (Table 7). This is contradictory
with the fact that in Colombia the number of medical schools have more than doubled
in the last 20 years and local universities had 3,285 matriculated students in the field of
Sciences of Health in 2008.
In addition, by creating a model clinic and managing it, BF will be able to generate a set
of quality standards for the services provided to its customers. This standardization will
not only ensure the proper delivery of care, but will also ease the future expansion and
replication of the model throughout Caldas.
Other than spaces for the actual care delivery such as doctors’ offices and nurses’
screening rooms, the clinic should also count on an affiliated pharmacy, from where
the customers can buy discounted medicines and healthcare products; a reception and
a waiting room, for managing the patients flow; a room for the fairies’ meetings and
training sessions and a BF office space, from where the main activities of this social
business will be managed and coordinated.
The healthcare personnel working at the clinic will be composed by family doctors, a
pediatrician, an internist, nurses, auxiliary nurses and a pharmacist. The administrative
personnel will include other than the receptionist/call center attendant, the BF network
management staff.
Besides the stakeholders directly involved in the social business, Bienestar Familia
will rely on key partnerships to fund, support and complement its activities. Local
universities with campuses on Sciences of Health will be an important source for
recruiting the healthcare personnel that will work on the clinic. Focusing on new
graduates will allow BF to give a fresh perspective to care delivery and will ease the
process of standardization.
Partnerships will also be made to complement the health services provided by BF and to
ensure a holistic approach to care. This partnerships will be made with local pharmacies,
clinical laboratories and medical imaging centers to give discounted services to BF
members. They in exchange will benefit of higher volumes for their businesses.
Financial partnerships should also be developed with key suppliers that are interested
in sponsoring the social business model. These suppliers can be pharmaceutical and
medical equipment companies, as well as ICT development ones.
Finally, Bienestar Familia would work in close contact with Grameen Caldas. They can
help finance the start up with their social business fund, give valuable consulting
services on social business and help in building the network of partnerships.
The following map explains the role and influence of each stakeholder inside the
Bienestar Familia system. Stakeholders of Bienestar Familia
Partners
Community
Bienestar
Familia
Human
Resources
Families
(Patients)
Receives quality and affordable healthcare for the whole family when enrolling in Bienestar
Familia. Helps the continuous improvement of BF by giving feedback through the Fairies.
Fairies Single mothers chosen by BF and the community to become a 2-way communication channel.
Sell BF plans, give information, collect feedback and give focused prevention and education.
Bienestar Familia Management Manages BF social business with the focus on giving affordable and quality healthcare to its
members while being self-sustainable. Oversees plan sales, internal processes, human and
financial resources, database and physical infrastructure and partnerships.
Family
Doctor
Deliver quality primary healthcare and establish a relationship of continuity and trust with the
patient. BF gives them fair salaries and the right conditions to perform quality work.
Specialist Doctors
(Pediatrician and Internist)
Complement the primary care services, deliver children-focused care and continuous treatment
for chronic patients. BF gives them fair salaries and the right conditions to perform quality
work.
Healthcare Personnel
(Nurses)
Help doctors during care delivery, initiate contact and check-up of the patient. Perform minor
treatments when needed. BF gives them fair salaries and the right conditions to perform quality
work.
Administrative
Staff
(Call-Center/Receptionist)
Manage efficiently the costumer flow and help create a stimulating environment. BF gives them
fair salaries and the right conditions to perform quality work.
Laboratories
& Pharmacies
Supply young doctors and other healthcare personnel to work on Bienestar Famila clinics.
Grameen Caldas Consultancy on Social Business. Increase network of partners. Access to Social Business Fund.
Medical Equipment Co.
Pharmaceutical Co.
& ICT Companies
Initial sponsors in the first phase. When business is running sponsors will be repaid and the
remaining stakeholders will instead be the only owners.
(Social business type 2)
Local
Universities
Supplies young doctors and other healhcare personnel to work on
BF clinics.

The Family Healthcare Plan & The Family Doctor
The following maps illustrate the steps that a patient needs to take in order to complete
a ﬁrst level treatment cycle. It starts with the public health system where the main
problems found are highlighted and then goes to Bienestar and the problems solved by
the social business pilot. The objective is to understand how Bienestar Familia would
intervene to improve the primary healthcare experience.
Comparing the two systems, it is evident that with Bienestar, a patient is able to skip
the ﬁrst part of the process, avoiding delayed treatments and economic losses due to
waiting time. Bienestar also improves the quality of care delivery, even though the
model is not able to guarantee it.
Public Health System Primary Care Cycle Bienestar Primary Care Cycle

Bienestar Familia, on the other hand, goes deeper in the changes, introducing other
than the family doctor, an ICT platform to manage patients’ medical files, the clinic’s
internal processes and the scheduling system. This platform will also serve as a
communication channel between BF and the Fairies, who will be able to access it from
their cell phones. The database improves the efficiency of the entire process by reducing
the paper work during service delivery and ensuring continuity of the treatments by
facilitating the access to the patient health history.
BF will also empower the nursing staff by giving them an active role in the care delivery
cycle. Nurses will initiate the patient screening before seeing their family doctor.
This will help doctors with their workload, allowing them to concentrate in the most
important part of the care.
Finally, Bienestar Familia will also offer families specific specialist services, such as
pediatricians and internists, to deal with the most complicated cases and to reduce the
number of patients that need to access the EPS services.
Bienestar Familia Primary Healthcare Cycle
Bienestar Familia Offering Map
Bienestar
Familia
Healthcare
Services
Medical Database access to medical records
efficiency
transparency
Call Center scheduling appointments
information
Healthcare
Family Plan
unified family plan
family doctor
access
Fairy healthcare plan sales
prevention and education
customer service
Family Doctor monitoring / prevention
diagnosing / intervening
Specialists
(Pediatricians + Internists)
monitoring / prevention
diagnosing / intervening
Pharmacy discounted medicines
As Bienestar needs to be an accessible solution to low income families while providing
high-quality services, it is important to understand the whole care cycle and to
standardize the care delivery process. A standardized process will serve as a reference
for the replicable model and future network expansion and will also allow the estimation
of costs involved in treating patients over their entire care cycle (Time-Driven Activity-
Based cost measuring system). Moreover, this approach combined with outcome
measurement enables the continuous improvement of Bienestar Familia’s services.
The blueprints on the following pages show how the two main processes of Bienestar
Familia’s healthcare value chain - the family doctor consultation and Fairies’ membership
sales and feedback collection - can be initially standardized. The same approach shall be
used in all other Bienestar processes.

Blueprint of Family Doctor ConsultationBlueprint of Fairies Service

Business Model of Bienestar Familia
The Business
Model Canvas
* Orange post-its represent the expansion phase of the business through an affiliate medical network.www.businessmodelgeneration.com
Revenue Streams
Channels
Customer Relationships Customer SegmentsValue PropositionsKey ActivitiesKey Partners
Key Resources
Cost Structure
Family care:
family doctors,
pediatricians &
internists
Family doctor
Fairies
Low income
Caldas families
Bienestar clinic
Fairies
Healthcare
delivery
Measure social
impact
ICT database
Brand
Local
medical
universities
Membership
sales
commissions
Salaries:
healthcare
personnel,
admin staff,
management
Clinic costs
(supplies +
utilities) Annual
membership fee
Visits +
treatments
Families
unsatisfied with
public healthcare
services
Call center
Staff
Grameen Caldas
Doctors
Laboratories
& pharmacies
Community
(Patients
& Fairies)
Initial
investment:
infrastructure
+ ICT
Improve access
to primary
healthcare for
low income
communities
Empower women
& creation of
jobs
Social and Environmental Costs Social and Environmental Benefits
- Fairies -
a dedicated link
between patients
and BF
Network
affiliation fee
Network
expansion &
management
BF managment
Lowers the
government’s
responsibilty in
providing adequate
healthcare
Family membership
that gives access
to quality, efficient
& discounted care

Implementation
& Expansion

Ownership
Implementation
Expansion
0. Bienestar Familia
implementation
1. Bienestar Familia starts
spreading after establishing
standard processes: VOLUME
2. Bienestar Familia has proven
to be sustainable and reliable
(break-even)
3. Bienestar (brand) broadens
scope of practice
Fairies Access: Representatives of families
can be chosen to become Fairies
and receive a greater discount on
health care services (or for free)
Commissions: Can earn additional
commissions from sales by their
‘downline’ healthcare promoters
= exponential awareness due to
**multi-level marketing (to be
controlled)
Specific training / Specialization:
Community Managers on-site
and database
and / or nursing
Specific training / Specialization:
Community Managers on-site
and database
and / or nursing
Pre-existing Healthcare
Providers
Volume: Ensure a large number of
patients to existing private clinics
Standardization: Healthcare cycles
to specific patient populations
and medical conditions need to be
established (use of Time-Driven
Activity-Based - TDAB - care to
measure costs)
Quality control: Standardizing
healthcare cycles will permit better
quality control and assignment of
Bienestar quality certifications
Bienestar Familia
Staff
Administrative: Social business
and business administration
IT Management: IT expert
(partner) or internships from
information / computer engineers
to build information system and
maintenance
Healthcare area: Young doctors
due to collaboration between local
universities and Bienestar Família
Bienestar Familia Staff: Fairies;
Management; Family Doctor;
Specialists (pediatrician +
internist); Nurses; Administrative
Staff (call center + receptionist)
+ Internships
Local Universities Stage: Students from computer
engineering and business
management universities can
have an internship with Bienestar
Familia administration
Stage: Students from medical
universities can have an internship
at Bienestar Familia Clinic
Experience: Fresh graduates get
the opportuniy to be a part of a
promising and innovative social
network inside the healthcare
sector
Principal Resources
Alternative Source
Risk Associated
Government of Caldas
Social Business Fund
Microfinance
Government of Caldas
Microfinance
Government Caldas
Microfinance
Revenues from cards
Revenues from visits
Revenues from ministry of health
Revenues from sponsors (ICT,
pharmaceuticals and medical
equipment companies)
Initial investment to build
Bienestar Familia Clinic
Government Caldas
Microfinance
Revenues from cards
Revenues from government health
ministy
Revenues from sponsors (ICT,
pharmaceuticals and medical
equipment companies)
Production Equipment
and Infrastructure
Bienestar Família cards
Office equipment
Marketing material (posters,
brochures)
Bienestar’s Família system
information: Medical data
base to which both doctors and
patients can have access to (if
this information is managed by
the representative of the family
(women) - check in time / check
out time / measuring periodical
outcome of the treatment / etc
- then less costs for Bienestar
Familia)
Bienestar Família Clinic:
1 reception + waiting room; 2
doctor offices; 1 nurse room; 1
dressing room; 1 pharmacy; 2
administration offices; 2 toilets;
1 storage room; 1 community /
meeting room
Integration: Bienestar’s Família
Cards and System Information (data
base with medical records) work
flawlessly together
Phase
Resource
HUMANRESOURCESFINANCIALRESOURCESMATERIALRESOURCES
Resources Mapping for Implementation Plan
**Multi-level marketing (MLM) is a marketing strategy in which the sales force is compensated not only for the sales they personally generate, but also for the sales of others they recruit,
creating a downline of distributors and a hierarchy of multiple levels of compensation.
The Bienestar Familia business model is designed to work as social business owned by
the community (social business type 2). In the initial phase, other stakeholders such as
ICT, pharmaceuticals, medical equipment sponsors or the Caldas government will take
part as investors. When business starts running properly, they will be repaid leaving the
community as the sole owners.
In every family there is a legal representative, preferably a woman, that becomes the
person interacting with the organization. The annual membership is a share family
representatives pay to enroll in the program making them owners / stockholders of
the Bienestar Familia initiative. This means the longer a family has been a member of
Bienestar Familia, the more shares the representative owns, becoming preeminent inside
the organization. This will guarantee the renewal of memberships.
This implementation plan is intended to be a guideline of potential sequences broken
down into 4 chronological phases. These are related to different types of resources
available allowing us to identify at what stage Bienestar Familia is ready to expand
through its affiliation medical network.
It is only possible when Bienestar Familia has achieved an important volume of patients
(achieved through Fairies and family plans), an established flawless system information,
and standardized care cycles for its patients.
From the implementation matrix, we were able to identify the phases that Bienestar
needs to go through in order to become a replicable model. This replicable model adapts
to different scenarios. Each scenario corresponds to a different type of healthcare
provider even if stakeholders are in some cases the same. Each of these scenarios can be
implemented once Bienestar Familia has reached all the phases of implementation.

3. Bienestar (brand)
broadens
scope of practice
Fairies Specific training /
Specialization:
Community Managers onsite
and database
and / or nursing
Pre-existing
Healthcare
Providers
Bienestar Familia
Staff
Bienestar Familia Staff:
Fairies; Management;
Family Doctor; Specialists
(pediatrician + internist);
Nurses; Administrative Staff
(call center + receptionist)
+ Internships
Local Universities Experience: Fresh graduates
get the opportuniy to be
a part of a promising and
innovative social network
inside the healthcare sector
Principal resources
Alternative source
Risk associated
Government Caldas
Microfinance
Revenues from cards
Revenues from government
health ministy
Revenues from sponsors
(ICT, pharmaceuticals
and medical equipment
companies)
Production
Equipment
and Infrastructure
Integration: Bienestar’s
Família Cards and System
Information (data base
with medical records) work
flawlessly together
Phase
Resource
HUMANRESOURCESFINANCIALRESOURCES
MATERIAL
RESOURCES
Bienestar Familia’s Replicable Model Expansion Through Affiliate Network
Scenario Stakeholders Ownership Location
AOpen New
Bienestar
Familia Clinic
Social Entrepreneur
Doctors / Specialists
The families (members) own
the new clinic (community
based ownership)
- social business type 2
Analogue services
To be expanded in different
areas
BOpen New
Bienestar
Familia Private
Office
Young doctors
Doctors own their private
office
Complementary services
To be expanded within the
same area
CBienestar
Familia
On Wheels
Young doctors
Doctors own their private
office
Complementary services
(primary care emergencies)
To be expanded in urban,
suburbs and rural areas

New Bienestar Familia Clinic New Bienestar Familia Private Office

New Bienestar Familia On Wheels
The Bienestar Familia Healthcare Network

Conclusion

As the public health system in Colombia is not able to provide adequate care delivery to the low income communities,
the Bienestar team saw a promising area of opportunity to start a social business. Nevertheless, during the pilot phase,
problems such as the sales and distribution of membership cards became more evident and the need to explore new
solutions was essential for the continuity of Bienestar.
Bienestar Familia Healthcare Plan is the result of a design process, with the objective of developing a solution to the
existing healthcare system in Colombia taking into consideration what Bienestar has already implemented.
Bienestar Familia focuses on improving the access of low-income families to high-quality healthcare by creating value
for the whole community:
- Generation of new job opportunities for women and decreasing brain-drain of qualified local doctors.
- Empowerment of women by giving them sense of ownership and responsibility over the organization.
- Establishment of a community-based healthcare infrastructure through a local network that enables Bienestar Familia
to provide other analogue services alongside the healthcare system.
At this point, Bienestar Familia is a prototype that needs to be tested. Taking into consideration the results gathered
from the prototype phase, Bienestar Familia would then be ready to be implemented in Caldas, Colombia. If the model
proves to be successful, a long term objective would be to adapt and replicate the model to fit in the specific context
of different countries.
Conclusion

Bibliographic References
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Humanity´s Most Pressing Needs (Pubblic Affairs , 2010)
» Erik Simanis and Stuart Hart, The Base of the Pyramid Protocol: Toward Next
Generation Bop Strategy (second edition 2008)
» Business Model Generation: A Handbook for Visionaries, Game Changers and
Challengers. Alexander Osterwalder and Yves Pigneur. Wiley, 2010.
» Richard J. Boland Jr. and Fred Collopy, Managing as Designing
(Stanford Business Books, 2004)
» C.K. Prahalad, The Fortune at the Bottom of the Pyramid: Eradicating Poverty
Through Proﬁts (Pearson Prentice Hall, 2009)
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accessed March 25th 2011, http://dschool.typepad.com/news/2009/12/the-bootcamp-
bootleg-is-here.html
» Diana Quintero, Jorge Garcia and Felipe Tibocha, Bienestar Business Plan, 2011
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sustainable innovation and design breakthroughs: a few questions for innovation”,
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philipsdesignpublication_unlocking_new_markets_pdesign_srocchi_230606.wpd
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Salud, Estrategia de BID 2011-014, (Banco Interamericano de Desarrollo, 2010)
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Salud Publica, 2009)
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design-toolkit/
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(World Resources Institute and International Finance Corporation, 2007)
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Pobreza
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Colombia
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sub-district-hospital
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101
Sanitation in the Indian Educational Context
An Opportunity Analysis
Sanitation in Schools

106 - India · Sanitation in Schools - D4SB 107107
Poverty in India remains a major issue where the country is estimated to have a third of the world’s poor, particularly
in rural areas. In order to spread and accelerate the social business movement, GCL has expanded and launched its
most recent office in Mumbai. In addition, the Yunus social business fund in Mumbai is currently under development in
order to encourage the initiation of social business by providing adequate funding across all social sectors in India.
As the Design for Social Business team, our challenge in India was to identify opportunities that can lead to the
improvement of sanitation, one of the country’s most pressing problems. With education being one of the most
important channels for penetration, we focused our design research on schools in rural and urban areas around
Mumbai for a better comprehension of the effects poor sanitation has on students’ attendance, dropout rates and
overall health.
Why India?

The
Indian
Context

111111
India Proﬁle
India in Numbers
Being the seventh biggest country by geographical area, the Independent Republic of India is the second most
populous country in the world. With over 1.17 billion people (2010 est.), India is projected to be the world’s most
populous country by 2025, with its population reaching 1.6 billion by 2050.
Rural and urban
populations
Literacy rate
(for people age 15
and above)
Poverty head count ratio
at national poverty line
Capital City: New Dehli
Income Level: Lower middle income
GDP: $1,729,010,242,154 (2010 est.)
GNI per Capita: $1,340 (2010 est.)
Total population in India
1.2 billion
Total population in Europe
852.4 million
Total population in the US
320 million
29%
urban
37%
illiterate
72.5%
not poor
71%
rural
63%
literate
27.5%
poor

total population
1.2 billion
total population
lacking access
to any kind of toilet
638 million
rural population
lacking access
630 million
total rural population
852 million
total population lacking
access to any kind of toilet
638 million
rural population
lacking access
630 million
Sanitation in India. An Overview
children under 5
die annually due to diarrhea
only
of India’s wastewater
is being treated

Culture and Religion
Muslim - 13.4%
Hindu - 80.5%
Others - 6.1%
Figure 3. The most common religions in India.
Understanding
Sanitation
Sanitation is understood as providing facilities and services that ensure the safe
disposal of human excreta (urine and feces), which are meant to avoid open space
defecation. The lack of infrastructure combined with inadequate sanitation practices
is a major cause of disease worldwide. Improving sanitation has proven to have a
significant beneficial impact on health both in households and across communities.
Sanitation also refers to the maintenance of hygienic conditions, through services such
as garbage collection and wastewater disposal.
BRAHMINS
Priests & Academics
KSHATRIYAS
Warriors & Kings
VAISHYAS
Business community
KSHUDRAS
Servants, subordinate to Vaishyas,
Khastriyas & Brahmins
DALIT
Untouchables, subordinate to all,
responsible for all the lower-order work
Figure 4. The caste system in India
There are about 18 official languages in India with Hindi and English being the most spoken. Most of its population is
Hindu followed by Muslims and other religions which include Sikhs and Christians among others.
India Caste System
The Hindu caste system hierarchically categorizes people based on their occupations where each person is born into an
unalterable social status. The four primary castes are: Brahmin (the priests), Kshatriya (warriors and nobility), Vaisya
(farmers, traders and artisans) and Shudra (tenant farmers and servants). The people born outside the caste system are
called Dalits or “untouchables”. The outcastes’ occupations, regarded as impure, include butchering, rubbish removal
and waste disposal.
Although today caste discrimination is officially illegal, it remains prevalent mostly in rural areas. The Indian
government has made strong efforts in minimizing the significance of the caste system through expanding education
and economic opportunity in the countryside.

» By increasing school attendance
» By building community pride and social cohesion
» By contributing to poverty eradication
Common Water and Sanitation Related Diseases Improved Sanitation
Sanitation Facilities and Practices
Among the inadequate sanitation practices, the one that poses the greatest threat
to human health is open defecation. When talking about proper sanitation, water
contamination cannot be excluded since in indiscriminate defecation, excreta often
finds its way into sources of drinking water and food and is the root cause of faecal-oral
transmission of diseases.
Unicef defines a list of common unimproved sanitation related diseases, which include:
Diarrhea, Cholera, parasitic worms, Typhoid, and Dysentery among others. Diarrhea
is the most important public health problem directly related to water and sanitation.
About 4 billion cases of diarrhea per year cause 1.8 million deaths, over 90% of them
(1.6 million) are among children under five.
Bush or field
Due to the absence of proper infrastructure, excreta is deposited on the ground and
covered with a layer of earth, wrapped and thrown into garbage or defecation is done
into surface water.
Bucket
Refers to the use of a container for the retention of faeces, urine and anal cleaning
material, which are periodically removed for treatment, disposal,
or used as fertilizer.
Hanging toilet / latrine
Refers to a toilet built over a body of water in which excreta drops directly.
Pit latrine
This facility uses a hole in the ground for excreta collection. In some cases, this
kind of infrastructure may have a squatting slab or seat raised above the surrounding
ground level to prevent surface water from entering the pit. An improvement in the
infrastructure consists of a ventilation pipe that extends above the latrine roof and is
covered fly-proof netting (Ventilated Improved Pit Latrine ‘VIP’).
Flush toilet
This kind of toilet uses a tank that flushes water and is sealed in order to prevent the
passage of flies and odors (also called water seal). A pour flush toilet also uses a water
seal, but in contrary to the normal flush toilet, it has no tank and uses water poured by
hand for flushing.
Composting toilet
A dry toilet into which carbon-rich materials are added to the excreta which is kept
in special conditions to produce inoffensive compost; it may or may not have a urine
separation device.
Piped sewer system
Piped system and facilities (sewerage) that collect, pump, treat and dispose human
excreta and wastewater and remove them from the household.
Septic tank
An excreta collection device consisting of a water-tight settling tank. Normally located
underground, away from the house or toilet, the treated effluent of the tank usually
seeps into the ground through a leaching pit or discharged into a sewerage system.
‘Improved’ sanitation facilities are those that reduce
the chances of people coming into contact with human
excreta and therefore becoming more sanitary than
unimproved facilities. These include:
» Toilets that flush waste into a piped sewer.
» Septic tank or pit.
» Dry pit latrines constructed with a cover.
These kinds of facilities are only considered to be
improved if they are private rather than shared with other
households.
Some 2.6 billion people worldwide – two in five – do not
have access to improved sanitation, and about 2 billion of
these people live in rural areas. According to the United
Nations, proper sanitation can foster social development,
which at its core, is about human dignity and human
rights. For the people who lack access to a proper
infrastructure and practice open defecation, human
dignity is under daily assault. A toilet can improve social
development in a number of ways:
» By aiding progress toward gender equality
» By promoting social inclusion
About 4 billion cases of
diarrhea per year cause 1.8
million deaths, over 90%
of them (1.6 million) are
among children under five.
Sanitation and the Millennium Development Goals (MDG)
One single gram of feces
can contain:
10,000,000 viruses
1,000,000 bacteria
1,000 parasite cysts
100 parasite eggs
Table 1. Parasites found in one gram of feces.
Table 2. Differences between improved and unimproved sanitation
facilities
Figure 5. Millennium Development Goal 7: Ensure Environmental
Sustainability
What is an improved facility?
Improved Unimproved
Flush or pour flush to:
» piped sewer system
» septic tank
» pit latrine
Flush or pour flush to
elsewhere.
Pit latrine without slab
or open pit
Ventilated improved pit
latrine (VIP)
Hanging pit or hanging
latrine
Bucket
Composting toilet No facilities (bush or
field); open defecation
Goal No. 7c. specifically states “Halve, by 2015, the
proportion of people without sustainable access to safe
drinking water and basic sanitation”. Which in this case
would be considered as access to improved sanitation
facilities.
Though proper sanitation has huge benefits in public
health, gender equity, poverty reduction and economic
growth, it is often a relatively low priority within the
official development plans. Domestic budget allocations
and official development assistance are often scarce, and
in many instances, interventions are not targeted to the
population most in need.
At the current rate of progress, the world will miss the
target of halving the proportion of people without access
to basic sanitation. Though global sanitation coverage
increased from 49% in 1990 to 59% in 2004. In 2008,
an estimated 2.6 billion people around the world lacked
access to an improved sanitation facility. If the trend
continues, that number will grow to 2.7 billion by 2015.
Figure 5. Icons showcasing a Western style toilet and a Squat toilet
that is more common in India.
Western style toilet
with flush
Squat toilet

water resources are polluted, and 80% of the pollution is
due to sewage alone.
Diarrhea accounts for almost one fifth of all deaths (or
nearly 535,000 annually) among Indian children under
5 years. Also, rampant worm infestation and repeated
diarrhea episodes result in widespread childhood
malnutrition. Due to this problem, India is losing billions
of dollars each year. Illnesses are costly to families,
and to the economy as a whole in terms of productivity
losses and expenditures on medicines, health care, and
funerals. The economic toll is also apparent in terms of
water treatment costs, losses in fisheries production and
tourism, and welfare impacts, such as reduced school
attendance, inconvenience, wasted time, and lack of
privacy and security for women.
Major factors that have impeded effective implementation
of a rural sanitation program include very low priority
given to sanitation as a social and community issue,
lack of infrastructure and systems to reach all rural
households, and most importantly, scarcity of water.
Sanitation in India
It is estimated that 55% of all Indians
(638 million) still lack access to any
kind of toilet. Of this total, people
who live in urban slums and rural
environments are affected the
most. In rural areas, the scale of the
problem is particularly daunting,
as 74% of the rural population
still defecates in the open.
India Sanitation in Numbers
Only 31% of India’s population use improved
sanitation (2008)
In rural India 21% use improved sanitation facilities
(2008)
145 million people in rural India gained access to
improved sanitation between 1990-2008
211 million people gained access to improved
sanitation in whole of India between 1990-2008
India is home to 638 million people defecating in the
open; over 50% of the population.
Table 3. India sanitation landscape in numbers.
India seems to be lagging behind MDG target values in almost all the
parameters under consideration. Human development hence remains to
be an area of concern. Education and health are the critical areas and
we continue to be distant from the targeted goals. Infant and child
mortality, undernourished population, as well as maternal mortality are
specific areas where much still needs to be achieved. Even though the
overall access to improved sanitation facilities has increased, the gap
between rural and urban areas is still very high.
It is estimated that 55% of all Indians (638 million) still
lack access to any kind of toilet. Of this total, people who
live in urban slums and rural environments are affected
the most. In rural areas, the scale of the problem is
particularly daunting, as 74% of the rural population still
defecates in the open.
In both environments, cash income is very low and
the idea of building a facility for defecation inside or
near the house may not seem natural. Where facilities
do exist, they are often inadequate. The sanitation
landscape in India is still littered with 13 million
unsanitary bucket latrines, which require scavengers to
conduct house-to-house excreta collection. Over 700,000
Indians still make their living this way.
The situation in urban areas is not as critical in terms
of scale, but the sanitation problems in crowded
environments are typically more serious and immediate.
In these areas, the main challenge is to ensure safe
environmental sanitation. Even in areas where households
have toilets, the contents of bucket-latrines and pits,
even of sewers, are often emptied without regard for
environmental and health considerations.
Sewerage systems, if available, suffer from poor
maintenance, which leads to overflows of raw sewage.
Today, with more than 20 Indian cities with populations
of more than 1 million people, the antiquated sewerage
systems cannot handle the increased load of wastewater.
These cities include Indian megacities, such as Kolkata,
Mumbai, and New Delhi. In New Delhi alone, existing
sewers originally built to serve a population of only 3
million cannot manage the wastewater produced daily by
the city’s present inhabitants, now close to a massive 14
million.
The capacity for treating wastewater is also acutely
inadequate, as India has neither enough water to flush-
out city effluents nor enough money to set up sewage
treatment plants. In 2003, it was estimated that only
30% of India’s wastewater was being treated. Much of the
rest—amounting to millions of liters daily— find its way
into local rivers and streams. According to the country’s
Tenth Five-Year Plan, three-fourths of India’s surface
India and the Millennium Development Goals (MDG)
Goal Indicator
Value
(Year)
MDG
target
Proportion of population below poverty line (%) 27.5
(2005)
18.75
Undernourished people as in % of population 76
(2005)
31.1
Proportion of undernourished children 46
(2006)
27.4
Ratio of girls to boys in primary education 0.94
(2007)
1
Literacy rate of 15 - 24 year olds 82.1
(2007)
100
Ratio of girls to boys in secondary education 0.82
(2007)
1
Under five mortality rate
(per 1,000 live births)
74.6
(2006)
41
Infant mortality rate
53
(2008)
27
Maternal mortality rate
254
(2006)
109
Rural population with sustainable access to an improved
water source (%)
79.6
(2008)
80.5
Urban population with sustainable access to an
improved water source (%)
95.0
(2008)
94
Rural population with access
to sanitation (%)
44.0
(2008)
72
Urban population with access
to sanitation (%)
81
(2008)
72
Deaths due to malaria per 100,000 2
(2008)
-
Deaths due to TB per 100,000 23
(2009)
-
Deaths due to HIV/AIDS 170,000
(2009)
-
Table 4. Progress towards achieving MDGs in India with goals related to sanitation highlighted in gray.

The Indian government provides free and compulsory education for all children up to the age of 14. The
country is still grappling with serious problems of inadequate access, quality and inefficiency in the
schooling system.
The school system in India works through 3 different models:
» Public
» Private
» Public Private Partnership (PPP)
Public private partnership (PPP) is an approach used by the government to deliver quality services to its
population by using the expertise of the private sector. In this arrangement, a private party performs
part of the service delivery functions of the government while assuming associated risks. In return, the
private party receives a fee from the government according to pre-determined performance criteria.
Such payment may come out of the user charges, through the government budget or a combination of
both. Broadly, PPP in school education can operate to provide (1) infrastructural services, (2) support
services and (3) educational services. The simplest being one in which the private partner provides
infrastructure services but the government provides educational and other support services. The second
type is where the private sector provides both infrastructure and support services. While the third type
is where the private sector provides infrastructure, support and educational services bundled together.
A variety of public private partnership already exists in the field of education, the most common being
the government aided schools system in the country. In 2006-07, 30.05% of higher secondary schools
and junior colleges, 27.15% of high schools, 6.75% of upper-primary schools, 3.19% of primary schools
and 5.15% of pre-primary schools were run by private institutions with substantial financial assistance
from the State Government.
Alliances with different NGO’s also play a strong role in assisting the State or the private sector to
complement the education system and to improve its effectiveness. The effectiveness of NGO action
is best in evidence in the successful schooling of underprivileged children, communities in remote
locations, scheduled caste, scheduled tribe and other children that face social barriers to education.
One of the key challenges of the education system in India is the universalization of good quality basic
education. Almost two decades of basic education programs have expanded access to schools in India.
The number of out of school children decreased from 25 million in 2003 to an estimated 8.1 million in
2009. Most of those still not enrolled are from marginalized social groups. Two issues remain:
» Reaching some 8 million children not yet enrolled and ensuring retention of all students till they
complete their elementary education (8th standard).
» Ensuring education is of good quality so it improves learning levels and cognitive skills.
» Also, India still faces challenges in providing quality Early Childhood Development programs for all
children.
The Education System In India Water, Sanitation & Hygiene in Schools
Unsafe water and unhygienic conditions not only have an adverse effect on the health of below five
year old children but also have an impact on the health, attendance and learning capacities of school
children.
The Plan of Implementation of the World Summit on Sustainable Development in 2002 emphasized
sanitation in schools as a priority action, while the Thirteenth Session of the United Nations
Commission on Sustainable Development in 2005 reiterated this position and also emphasized the need
for hygiene education in schools. Providing adequate water and sanitation in schools is essential if
the enrollment, learning and retention of girls is to improve, and is key to meeting MDGs 2 and 3. Lack
of appropriately private and sanitary facilities has a greater impact on girls than boys, contributing
to decisions on whether they ever attend, and then influencing how long they stay in school. Girls
sometimes do not attend school during menstruation or drop out at puberty because of a lack of
sanitation facilities that are separate for girls and boys. In addition, adolescent girls are particularly
at risk of anaemia aggravated by parasitic infections and ‘iron stress’ when sanitation is inadequate or
unavailable at school or at home.
All children perform better and have enhanced self-esteem in a clean, hygienic environment. Properly
used and maintained sanitation facilities and an adequate supply of water for personal hygiene and
hand washing prevent infections and infestations, while also contributing to overall public health and
environmental protection. Programs that combine improved sanitation and hand-washing facilities
with hygiene education in schools can improve the health of children for life and can promote positive
change in communities. Field assessments show that teaching children the importance of hand washing
and other good hygiene habits promotes increased knowledge and positive behavior change, especially
when the schools are equipped with an adequate number of safe toilets or latrines and sufficient water
for washing.
Adolescent girls are particularly at risk of anaemia aggravated by
parasitic infections and ‘iron stress’ when sanitation is inadequate
or unavailable at school or at home.

4a Co-Living - Tiago Miranda - Social design projects

4a Co-Living - Tiago Miranda - Social design projects

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